September 12, 2014
3 minute read

Common Health Insurance Terms And Definitions

We get it. Health insurance can be about as easy to understand as an entirely different language; so we really try to make it as easy as possible for people. A good way to start is to take a look at some of the most common health insurance terms and definitions.

First, three terms you’ll encounter quite a bit: premium, deductible, and co-pay.

Premium is the amount you pay monthly, quarterly or semi-annually to your insurance company for insurance coverage. The cost of your premium depends on the insurance plan you select as well as other items such as your location, age, family size, and tobacco use.

Deductible is the amount you are responsible for paying for care before your health insurance plan begins to pay. The deductible is on an annual basis, meaning after you have satisfied the deductible in a given year, you are not subject to it for the rest of the year.

Co-pay, also known as a co-payment, is a fixed amount that you pay for specific health care services such as doctor’s visits or prescription drugs. The amount of your co-pay can vary depending on the type of health care service.

Now that you know those basic terms and definitions, what’s with the acronyms? PPO, HMO, EPO.

A PPO (Preferred Provider Organization) is a health insurance plan that offers you the options of obtaining health care from providers (doctors and hospitals) that are either within or outside of a provider network. Preferred providers are considered “in-network” and will cost less than if you use out-of-network providers.

An HMO (Health Maintenance Organization) is a health insurance plan that typically requires  you to choose a primary care physician who will coordinate all of your health care. In an HMO plan, if you want your insurance to pay for health care costs, you must choose providers that are considered in-network and you’ll be required to obtain a referral from your primary care physician to see a specialist however they typically allow a member to have lower out-of-pocket costs.

An EPO (Exclusive Provider Organization) is a network of doctor and hospital providers, just like a PPO.  However, you are restricted to exclusively using only those providers or the EPO won’t pay, there are no out-of-network benefits.  With an EPO plan, you can see any in-network provider without needing a referral.

So what about these gold, silver, bronze and platinum plans? Isn’t gold always the best one? Not so fast. The best plan is the one that’s right for you, depending on premium cost and desired coverage.

A Bronze plan is a health plan where the actuarial value is 60%, which means on average a consumer can expect to pay roughly 40% of the cost of health care while the insurance company picks up 60%.  Bronze plans generally have the lowest premium cost per month.

A Silver plan has an actuarial value of 70%, meaning a consumer can expect to pay roughly 30% of the cost of health care while the insurance company picks up 70%.

A Gold plan has an actuarial value of 80%, which means a consumer can expect to pay roughly 20% of the cost of health care while the insurance company picks up 80%.

A Platinum plan has an actuarial value of 90%, meaning a consumer can expect to pay roughly 10% of the cost of health care while the insurance company picks up 90%.  Platinum plans generally have the highest premium cost per month.

We hope that we’ve helped to shed some light on a few common health insurance terms and definitions. Don’t hesitate to reach out with questions or to let us know if you’re currently looking for the right plan. Call us 24/7 at (800) 827-9990, to talk to one of our friendly representatives or visit HealthMarkets.com to find a licensed health insurance agent near you.

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© 2022 HealthMarkets Insurance Agency. All rights reserved.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1- 844-704-7357), 24 hours a day/7 days a week, to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency in all 50 states and DC. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMIA000659

© 2022 HealthMarkets Insurance Agency. All rights reserved.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1- 844-704-7357), 24 hours a day/7 days a week, to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency in all 50 states and DC. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMIA000659

© 2022 HealthMarkets Insurance Agency. All rights reserved.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1- 844-704-7357), 24 hours a day/7 days a week, to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency in all 50 states and DC. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMIA000659